#6. The nonfrank breech. We have already seen how it can pose some particular problems. If one decides to attempt a vaginal breech birth, one should take, at a minimum, 3 precautions: keep the membranes intact until full dilation; be on guard for cord presentation or cord prolapse; at the moment of expulsion, slow the emergence of the foot/feet for at least a little while by pressing one hand against the vulva.

By implication, the last precaution refers specifically to breeches emerging feet-first, aka footling breech, and perhaps also to a complete breech with the foot/feet slightly in front of the buttocks. The French obstetrical nomenclature doesn't generally have a specific term for footling, just nonfrank (siège complet) and frank (siège décomplété).

Dubois' recommendations do not mention the goal of converting leg position, but that could be a side result of counter-pressure against the feet. This technique could provide additional time for the cervix to dilate, if not already fully dilated.

Monday, February 05, 2018

Severe acute maternal morbidity (SAMM) is a maternal life-threatening event shortly before or after childbirth, often referred to as a "near miss."

Mantel et al (1998) describe a near miss as "a patient with an acute organ system dysfunction, which if not treated appropriately, could result in death." In other words, "A very ill pregnant or recently delivered woman who would have died had it not been that luck and good care was on her side."

In 2010, van Dillen et al published a study about severe acute maternal morbidity in The Netherlands. Following all pregnant women nationwide, they found that SAMM occurred 6.4 times per 1000 after elective cesarean section, compared to 3.9/1000 after planned vaginal birth. The risk of SAMM after a cesarean section persisted into the next pregnancy. The authors report: "Women with a previous CS were at increased risk for SAMM in their present pregnancy."

I created an infographic that represents those findings. Whenever a woman faces the possibility of a cesarean section, the short- and long-term risk to herself should be part of the discussion.

Friday, February 02, 2018

How likely is a woman to have a cesarean when she is in labor with a breech baby? Is there any way to predict her chances of a vaginal birth based on how dilation and estimated fetal weight?

A teaching hospital in Liverpool compiled data on all singleton term and near-term breech babies born in their unit between 1988 and 1991. Nwosu et al (1993) calculated the likelihood of having an in-labor cesarean based on both estimated fetal weight and cervical dilation at admission. They explain:

Recently Chadha et al (1992) have shown that women admitted in labour with breech presentation at a low cervical dilatation (less than 3 cm) are more likely to be delivered by caesarean section. This is in agreement with our study. Using our results for all vaginal and emergency caesarean deliveries, we are able to tabulate the likelihood of caesarean section corresponding to various values of cervical dilatation on presentation and estimated fetal weight. These results are presented as Fig. 1 (Callygram), which could assist the clinician on the labour ward in counselling the woman, and in the choice of the best mode of delivery. It must be stressed that the tabulated (percentage) probabilities of caesarean section for given values of cervical dilatation and fetal weight are derived from our sample which has not specifically addressed the question of augmentation of labour [this unit did not induce or augment] and intrapartum external cephalic version (with or without tocolytics).

As you can see, the likelihood of a successful vaginal birth increases significantly with higher cervical dilation at hospital admission. EFW also plays a role, but that difference nearly disappears at both extremes of cervical dilation.

Cervical dilation at admission depends on how long the mother waits to go in, so this is a tricky thing to use as a predictive measure. There is no automatic set point at which women go to hospital (or, at home, call their midwife). A woman's likelihood of a vaginal breech birth also varies widely by hospital and by provider. But this does suggest that a rapidly progressing labor is a strong positive indicator of a successful vaginal breech birth.

Monday, January 29, 2018

Recent studies do not support the findings of the 2000 Term Breech Trial, a randomized controlled trial that enrolled 2,088 women.

Two large multi-center studies in France and Belgium found no difference in perinatal/neonatal mortality between planned CS and planned vaginal birth. These studies--one prospective, one retrospective--followed a total of 10,200 women and had 174 & 175 participating hospitals.

Some national registry studies have found no significant differences between planned CS and planned vaginal breech birth.

A meta-analysis and other registry studies have found some advantage to planned CS, but the advantage is significantly less pronounced than in the Term Breech Trial.

Sunday, January 28, 2018

Each year around 6,490 women in the Netherlands (40%) still plan a vaginal breech birth. This number is significantly lower than it was before the 2000 Term Breech Trial, where roughly 75% planned a vaginal breech birth and around 50% overall gave birth vaginally to their breech babies (see Rietberg et al 2003).

A national registry study by Vlemmix et al (2014) calculated the anticipated neonatal benefits if these remaining 6,490 Dutch women all planned c-sections.

If all women who nowadays still undergo a planned vaginal breech birth were to receive an elective cesarean, 6490 more elective cesareans would be performed. This would lead to an additional annual reduction of 10 neonatal mortalities, 116 neonates with low Apgar scores and 20 neonates with birth traumata.

This calculation only considers short-term neonatal benefits--not long-term neonatal outcomes, not short- or long-term maternal outcomes. Here is another way of understanding these numbers:

In several national registry studies, planned CS for breech leads to small but measurable improvements in short-term neonatal outcomes (mortality and morbidity). However, these improvements are consistently much smaller than the Term Breech Trial's findings.

This pressing question remains: at what point do the short- and long-term risks of routine cesarean begin to outweigh the short-term benefits to the baby? How many elective cesareans are justified to save 1 baby? What if women are forced into having these cesareans?

A policy of routine cesarean for breech does not allow women to decide what the acceptable risk/benefit trade-off is.

Friday, January 26, 2018

Making a decision about how to birth a breech baby involves a complex risk calculus. Women have to weigh the short- and long-term benefits to themselves, their babies, and their future pregnancies. This graphic (created for me by Lauren McClain of Better Birth Graphics) shows how planned CS for breech has affected women and their babies in the Netherlands. Verhoveen et al (2005) discuss the effects of the increase in planned CS since the Term Breech Trial, and the results show a risk trade-off.

Between 2001-2005, 8,500 women in the Netherlands had a planned CS for breech. This increase in pCS saved an estimated 19 babies, but it also led to 4 direct maternal deaths, 9 additional babies dying in future pregnancies due to the uterine scar, and 140 additional life-threatening maternal complications in future pregnancies.

Sunday, January 21, 2018

In preparation for my Jan 24th Indie Birth webinar--Is vaginal breech birth safe?--I wanted to share this series of graphics I have created. These will be explained in more detail during the presentation.

This first illustration shows neonatal and/or perinatal mortality rates from the Term Breech Trial, two large multi-center studies in France & Belgium (PREMODA and Vendittelli), a meta-analysis of several single-center studies (Krebs), and then a series of national registry studies.

These are all studies of term breech births of singleton fetuses alive at the beginning of labor with congenital anomalies excluded (exception: the TBT also included antepartum stillbirths).

On the right of the graphic is the type of mortality studied:

PNM/NNM: intrapartum deaths + neonatal deaths up to 28 days

PNM: intrapartum deaths + neonatal deaths up to 7 days

NNM: infant deaths through 28 days; intrapartum stillbirths excluded

For Vlemmix, Vistad, Hartnack-Tharin, and Vistad, I included only the data from the later time periods (usually post-TBT).

The next slide shows the same dataset, adding in planned cephalic births (vaginal & cesarean) analyzed in two of the registry studies.

The last slide shows the relative samples sizes of the various studies. On the right side, you can see the sample sizes of the pVBB and pCS groups.

Thursday, January 18, 2018

This presentation reviews research on term breech that has emerged since the 2000 Term Breech Trial. From a PubMed search of “breech” and “pelvic presentation” in the title & abstract, I extracted over 1,900 articles published between 2000-2017.

I examine the evidence on term breech broken into several categories: neonatal morbidity, perinatal/neonatal mortality, long-term childhood outcomes (1-18 years old), short-term maternal morbidity, maternal mortality, long-term maternal outcomes, and outcomes for the mother’s future babies. I examine where the evidence falls for term breech in developed versus developing countries and for breech birth at home. I present research updates on other relevant topics, such as upright breech birth and the role of maternal positioning in altering the dimensions of the pelvis. I also discuss how vaginal breech skills help make cesarean sections safer for head-down babies that are deeply wedged in the maternal pelvis.

I finally put all of the evidence together—short- and long-term for both mother and child and the mother’s future babies—and demonstrate the complex risk calculus involved in answering the question, “Is vaginal breech birth safe?”

Time: Jan 24 at 3 pm EST (12 pm PST, 9 pm in Western Europe) or listen later to the recordingCost: $30Duration: approx 90-120 minutes, including time for Q&A

If you can't listen live, you will also be able to access the recording. Please register today!

Saturday, December 16, 2017

Dr. Annette Fineberg, an OB at Sutter Davis Hospital, has requested letters of support from women who have had breech babies. She is experienced in vaginal breech birth but has encountered significant roadblocks from her hospital. She has also been unable to get privileges at a nearby tertiary hospital to do breeches there.

Please write letters of support for keeping the option of vaginal breech birth available! More details below from the OB:

I need to ask a favor from anyone who

1) had a vaginal breech birth in the hospital,
2) had one at home because that was your only option, or
3) was pressured into a cesarean because it was not an option due to hospital policy or lack of experience of attendant

I am getting a lot of pressure to stop attending breech and despite my best efforts to get privileges at a tertiary care hospital with neonatology, it is not happening.

Please send your impassioned pleas and experiences to:

Sutter Davis Hospital Birth Center
2000 Sutter Pl
Davis CA 95616

Thanks!

[And please also send me a copy of your letter so I can forward it on to the OB!]

Intrapartum external cephalic version (IP ECV) is strategy for avoiding both a cesarean and the risks of vaginal birth in a singleton breech presentation, especially for unfavorable presentations such as footling breech.

Kaneti et al (2000) analyzed a prospective series of in-labor ECVs for unengaged term footling breeches with intact membranes. Of 21 eligible women, 8 chose cesarean section and 13 chose IP ECV. 12/13 versions were successful and 10/12 women gave birth vaginally. Of the two failed vaginal births, one was for cord presentation and the other for arrest of labor. The babies were turned between 2-8 cm dilatation.

All women were multips; the physicians would have been willing to attempt IP ECV in primips as well, but never had the opportunity. The ECVs were done in the OR with Ritodrine and regional anesthesia when possible. The woman with an unsuccessful ECV went straight to cesarean while the twelve women with successfully turned babies received amniotomy and continued their labors in the labor ward. The one failed ECV was with a woman at 8 cm whose membranes ruptured at the beginning of the version. There was no maternal or neonatal morbidity, and all Apgars were 9 or 10.

Ferguson and Dyson (1985) report on a similar series of 15 women in labor with term breech presentations and intact membranes. Earlier in the study period, they had attempted IP ECV on women with ruptured membranes, but with no success. The authors do not specify type of breech presentation, other than that the women were not considered good candidates for vaginal breech birth. 6 were primips and 9 were multips.

They followed a similar protocol to Kaneti’s (versions were done in the OR under tocolysis between 1-8 cm dilation; successful versions were returned to the labor ward). 3/15 had epidural anesthesia during the version. 11/15 versions were successful (2/6 for primips, 9/9 for multips) and 10/11 women gave birth vaginally. The one failed vaginal birth was due to arrest of labor in a primip. Maternal and neonatal outcomes were good.

Leung, Pun, and Wong (1999) mention performing IP ECV on 5 out of 28 undiagnosed breeches in early labor, of which 2 turned successfully and both ended in vaginal births.

Belfort (1993) includes a case report of a multiparous woman presenting in labor with an unengaged complete breech with both feet palpable through the intact membranes. When she was 5 cm and 70% effaced, an IP ECV was performed in the delivery room with IV nitroglycerin. The procedure was successful. The woman received amniotomy and oxytocin to restart contractions and had an uneventful vaginal birth 8 hours later.

Monday, November 20, 2017

This summer I was listening to Dr. Stu's Podcast while repainting the windows on my carriage house. (Whenever I listen to something memorable, I also distinctly remember the location where I was listening--does the same thing happen to you?) It was an episode about Consent for a forced cesarean.

If all women being forced into unwanted cesareans asked their hospitals to sign this consent form before their surgery, hospital bans on vaginal birth for breech, twins, and VBACs might change overnight.

The consent form documents that the woman does not consent to the surgery, that ACOG's guidelines allow for vaginal birth in these situations and forbid the use of force or coercion, and that the hospital will be responsible for any complications due to the surgical birth, both short- and long-term.

Dr. Stu has invited everyone to download, edit, and distribute his consent form widely.

Sunday, November 19, 2017

We had a relaxed birthday party this year. I didn't even try to do something as amazing as last year's outdoor obstacle course. This time we baked cupcakes and bought lots of toppings...and that was it! The kids played indoors, since it was raining the entire day. They slid down the stairs on a mattress, danced with a strobe light, and played hide & seek and sardines.

Wednesday, November 08, 2017

What an amazing week I just spent at the Life Birth Pelvis conference in St. Petersburg, Russia! It was challenging and overwhelming (in a good way). This is the 8th international conference that Katerina Perkhova has organized.

Some thoughts, in no particular order:

Breech knowledge doesn't always cross political or linguistic borders
I gave two presentations on breech birth: one on the history of maneuvers from 1609 to the present, the other on evidence on term breech since the Term Breech Trial. Everyone involved with breech birth in North/South America, Europe, Australia/New Zealand, and many parts of Africa and Asia is familiar with the Term Breech Trial. But not Russia! "What is this Term Breech Trial you are speaking of? We have never heard of it." I had to explain the background and significance of the TBT in order for my presentation to make sense.

Conversely, Russians were quite familiar with Tsovian, aka the Tsovyanov. I suspect they were surprised we didn't know about him! I have now discovered 15 obstetric journal articles about his methods in Russian, Czech, Hungarian, Polish, and--in one case--Spanish. I also found contemporary Czech textbooks that mention Tsovian (spelled Covjan--sneaky Czechs making it harder for me!) and a Dutch article examining whether Bracht's or Tsovian's methods came first.

I am so excited that I get to help breech knowledge cross political and linguistic boundaries! My wonderful translator Alesya is excited to translate the articles and book chapters I am working on. And perhaps some of my breech conference summaries...

Hot & Cold Water
I was puzzled at how hot and cold water were frequently suggested as remedies. Your newborn needs resuscitation? Use hot and cold water! Is your premature baby having a hard time nursing? Hot and cold water!

I didn't fully understand this concept until I did a full Russian sauna on the last night of the conference. This includes going naked into the sauna, being beaten with bunches of oak leaves (it feels heavenly, like the heat is being beaten deep into your body), and then plunging into an ice-cold pool of water. And then doing it again several times. After the fourth cycle, I got the biggest endorphin rush of my life--comparable to being in labor. You know the dizzy, buzzing, high feeling you get all over your body between contractions? That endorphin rush. It lasted for about 2 hours.

And then I got it. Hot and cold water as therapeutic? As a way to maximize health and well-being? Yes, for sure! I have a friend here in the States who is a Russian translator, and she says that Russians often use the expression "tempering the baby," as one would temper steel with repeated applications of heat and cold.

In Western (is that the right word?) obstetric practice, we're concerned about getting the baby warm and dry immediately. Allowing a baby to be cold and/or wet is absolutely verboten. Maybe we could learn something from the Russian use of hot and cold water.

Right brain, left brain
This was the most right-brained conference I have ever attended. We had one "normal" conference room with rows of chairs and a projection screen for Powerpoint slides. This is where I gave my two breech lectures, a talk on unassisted birth, and a session on newborn resuscitation with Sister Morningstar.

But our other conference room was a Red Tent room. The walls were draped with red fabrics, the chairs were replaced with bean bags, and candles and incense and altars took the place of projectors and pointers. The floors were covered with intricately embroidered fabrics. In the corners were private alcoves for doing yoni steams, draped on all sides with red fabric.

Days were partially left-brained, partially right-brained, but evenings and nights turned magical and mystical. Sometimes intimate and sacred, sometimes raw and brutally honest, but always healing. Having Sister Morningstar, a Cherokee midwife, to lead the evening sessions was an honor. I've been quite cynical about religion lately, and these five days were a reminder that women have tremendous spiritual power and that spirituality in its widest sense is so much grander than anything one religion can offer.

Location: private home of Hermine Hayes in SW Portland, near Lewis and Clark College
(exact address will be provided to those who RSVP)

RSVP to: Jesica Dolin - jesicadolin@yahoo.com

This session will share information regarding the history of breech maneuvers from 1609 to the present. The presentation begins with a historical journey through obstetrical maneuvers for breech presentation. It documents every maneuver that has been uncovered by Rixa's research, tracking them back to their original inventors and dates, when possible. Next, she looks at current innovations in upright breech birth. The presentation tracks how knowledge about upright breech birth emerged and converged over the past several decades. Rixa will describe the key principles of upright breech birth and the physiological mechanisms of normal breech birth. She'll then review the maneuvers that have been invented to deal with stuck heads and arms when the mother is upright. The session will also cover the evidence on term breech since the 2000 Term Breech Trial.

Friday, October 13, 2017

Whenever I pull Michel Odent's book Birth Reborn off the shelf, it feels like phoning a dear friend after a long absence. We catch up on life and I remember why I enjoy this person so much.

Michel Odent is a French surgeon and obstetrician who was in charge of the Pithiviers Maternity Unit for over 20 years. At a time when cesarean rates were rising and births in France were highly medicalized, Odent turned the maternity wing at his state hospital into a haven for undisturbed, physiological birth. Most of his changes were low-cost and low-tech: creating an environment in which women were private and completely undisturbed during labor. He replaced delivery tables with big, low mattresses and cushions, birth pools, and simple furniture to aid spontaneous movement. His maternity unit had a 6-7% cesarean rate during the 1970s and 80s, even though it accepted an unscreened population.

I just opened Birth Reborn after a good year or two and turned to a section on breech birth. In his words and photos (pages 103-105 in the 2nd edition):

~~~~~

Finally, within the realm of labor and birth, one quickly learns to expect the unexpected. Sometimes a woman will have a quick and easy labor when professionals believed only a cesarean was possible. For example, women who have previously had a cesarean are sometimes told that they will always give birth that way. Yet at our clinic, one out of two women who have previously had cesareans succeed in giving birth vaginally. Nor do breech deliveries always justify the operation, although this has, nevertheless, become almost the rule in many conventional hospitals. From our experience with breech babies, we have found that by observing the natural progression of first-stage labor, we will get the best indication of what to expect at the last moment. This means we do nothing that will interfere with first-stage labor: no Pitocin, no bathing in the pool, no mention of the word "breech." If all goes smoothly, we have reason to believe the second stage of labor will not pose any problems. Our only intervention will be to insist on the supported squatting position for delivery, since it is the most mechanically efficient. It reduces the likelihood of our having to pull the baby out and is the best way to minimize the delay between the delivery of the baby's umbilicus and the baby's head, which could result in the compression of the cord and deprive the infant of oxygen. We would never risk a breech delivery with the mother in a dorsal or semi-seated position.

If, on the other hand, contractions in the first-stage labor are painful and inefficient and dilation does not progress, we must quickly dispense with the idea of vaginal delivery. Otherwise we face the danger of a last-minute "point of no return" when, after the emergence of the baby's buttocks, it is too late to switch strategies and decide on a cesarean. However, although we always perform cesareans when first-stage labor is difficult and the situation is not improving, most breech births in our clinic do end up as vaginal deliveries.

Here is a brief video of a breech birth at Pithiviers. Notice that the baby does not rotate to sacrum-anterior after the trunk is born (the most likely culprit is a nuchal arm). Odent steps in right away and frees the arm. The baby is born very quickly.

Thursday, October 05, 2017

English obstetrician Benjamin Pugh (1715-1798) is best known for inventing curved obstetric forceps and for his 1754 book A Treatise of Midwifery (PDF). He is less well known for innovating two ways to bring oxygen to a breech baby with a trapped after-coming head.

Pugh first created a flexible curved air-pipe, which would be inserted into the baby's mouth to the larynx. He next innovation was to create an airspace by manipulating the soft tissues inside the baby's mouth, with no need for the air-pipe.

Although it has received less notice [than his curved forceps], Benjamin Pugh made a considerable contribution to neonatal resuscitation. In his Treatise he describes and illustrates his air-pipe (Fig. 2):

‘‘The air-pipe, as a big as a swan’s quill in the inside, ten inches long, is made of a small common wire, turned very close (in the manner wire-springs are made) will turn any way; and covered with thin soft leather, one end is introduced with the palm of the hand, and between the fingers that are in the child’s mouth, as far as the larynx, the other end external.’’

Pugh initially advocated the use of his air-pipe in cases of breech extraction during delay in delivery of the after-coming head. He used the air-pipe in the manner quoted above as ‘‘I found many children were lost in this situation, for want of air…’’ Pugh then described an alternative method which he had developed making the use of his air-pipe rarely necessary:

‘‘You must then introduce the fingers of your left hand into the vagina, under the child’s breast, and put the first and second fingers into the child’s mouth pretty far, so far, however, that you are able to press down the child’s tongue in such a manner that by keeping your hand hollow, and pressing it upon the mother’s rectum, the air may have access to the larynx, you will soon perceive the thorax expand, as the air gets into the lungs.’’

Pugh emphasised the risk of asphyxia to the fetus during delivery of the after-coming head of the breech saying ‘‘…every operator must know there is difficulty, and grave danger of losing the child by its stay in the passage; by my method of giving the child air, I have saved great numbers of childrens’ lives, which otherwise would have died’’. Furthermore, Pugh goes on to give a remarkable early description of mouth-to-mouth respiration.

‘‘If the child does not breath immediately upon delivery, which sometimes it will not, especially if it has taken air in the womb; wipe its mouth, and press your mouth to the child’s, at the same time pinching the nose with your thumb and finger, to prevent the air escaping; inflate the lungs, rubbing before the fire: by which method I have saved many.’’

Wednesday, October 04, 2017

Announcing our newest baby K. Kawai, measuring 6'8" (2 meters) and weighing in at a whopping 772 lbs (350 kg). We found a lovely church putting her up for adoption far below market value. She traveled all the way from Dayton, OH to join our family.

Ivy and Eric were present for the delivery. What an experience! It was a battle going up the front stairs, but fortunately both home and baby are doing well.

K. Kawai has her first well-piano visit next Monday. So far she's been playing like a champ, so she should only need minimal tuning.

Last month K. Kawai's older sister (7'6") had to rejoin her grandparents back in Minnesota. The house has been far too quiet since she left.

Visiting hours are afternoons from 3-5. Please bring the new parents sheet music. (We are allergic to 12-tone music, otherwise we play anything.)

Tuesday, October 03, 2017

My most recent discovery while digging through medical archives: a 1901 British Medical Journal article about about breech presentation by Dr. Herbert R. Spencer, an obstetrician in London. He writes about the risks of breech birth, which to a modern reader, are astonishingly high. He strongly advocates for external cephalic version as a solution to the dangers of breech presentation.

While the middle of the paper was informative, the beginning and end, quoted below, were brilliant. I enjoyed his dry sense of humor and his ability to capture the reader's interest.

THE DANGERS AND DIAGNOSIS OF BREECH PRESENTATION, AND ITS TREATMENT BY EXTERNAL VERSION TOWARDS THE END OF PREGNANCY.

By HERBERT R. SPENCER, M.D., B.S.LoND., F.R.C.P.

Professor of Obstetric Medicine in University College, London; Obstetric Physician to University College Hospital.

BMJ, May 18, 1901

Pliny in his interesting Natural History informs us that it is contrary to nature for children to come into the world with the feet first, and that those who did were called "Agrippa"' from the fanciful etymology aegre partus, or "born with difficulty." This mode of delivery was thence known as the Agrippine birth. Pliny tells us that M. Vipsanius Agrippa was almost the only instance of good fortune among those who were born in this way. "And yet," he writes, "even he was affected by the unfavourable omen of his birth, as shown by the unfortunate weakness of his legs, and his short life" (which perhaps might have resulted from his abnormal birth) "and by the wicked lives of his wife and children," which we shall be less disposed than Pliny to attribute to the mere mode of delivery. I give this quotation from Pliny as it shows the existence amongst the Romans nearly 2,000 years ago of a belief in the difficulties attending and the disabilities following delivery by the lower extremity….

[External cephalic version], of course, involves the necessity of the patient's being examined during pregnancy, a necessity which is not recognised by all doctors or patients. Yet it is time that this examination became a routine practice, for without it patients and their infants are occasionally brought into the greatest peril, and not rarely lose their lives. As a result of this routine examination conditions may be recognized which can be obviated by timely interference. I believe the presentation of the breech to be one of these conditions; and I am sure that its treatment by external version during pregnancy is so free from objection that it is worthy of extensive trial. It is in the hope that others may be induced to practise it that I have ventured to publish such a small number of cases. It would be a great gain to be able to prevent this dangerous presentation, and to be sure that the child would always present by the head; for, in the words of Pliny, it is natural for man to come into the world by the head and to be carried to the grave by the feet--"Ritu naturae mos est capite gigni pedibus efferri."

Friday, September 15, 2017

In resource-rich countries, the debate about how to best deliver breech baby is largely focused on reducing a very small risk of death or serious disability at the price of increased maternal mortality and morbidity and problems in future pregnancies. However, in the developing world, the debate around breech has a unique set of implications and consequences. In resource-poor countries, perinatal mortality rates are often high, health infrastructure is low, and providing even basic care to all pregnant women is a challenge. Cultural values about vaginal birth and attitudes towards cesarean sections may also differ from the developed world.

Below are excerpts from several articles published after the 2000 Term Breech Trial that examine breech birth in developing countries. (I was working alphabetically through my reference list. I started compiling excerpts while on letter "I," hence the lack of authors from A-H).

The implication of this finding is that in well selected patients, neonatal outcome following assisted vaginal breech delivery and planned caesarean section may not be different. Owing to the high level of aversion to caesarean section by our women (Aziken et al., 2007; Ezechi et al., 2004), as well as the associated surgical risks, a whole scale policy of caesarean section for all cases of term breech delivery may not be feasible in our environment. Moreover, the policy will inevitably lead to an overall increase in caesarean section which will put a strain on the very limited resources in the region. As breech presentation is not a recurrent indication for caesarean section, most of these women who had caesarean section will attempt vaginal delivery in their subsequent pregnancies with the associated risk of uterine rupture. Owing to the very high premium placed on vaginal delivery by the African women and the fear of a repeat caesarean section, a significant number of these women may not present to a proper health facility for management. The consequence is increased likelihood of uterine rupture and the attendant maternal mortality and morbidity.

Furthermore, in Africa, labour and delivery are not just medical matters, but carry a huge cultural significance. Any intervention that will affect the attitude of the people towards labour and delivery must consider the cultural aspect.

It is impossible to deliver all term breeches by CS, as a systematic review has suggested 9% of women still have a vaginal breech delivery (Conde-Agudelo 2003). This is due to: maternal request; advanced or precipitate labour; or the presence of a second fetus in twins. This further highlights that the obstetrician providing intrapartum care should be able to conduct vaginal breech delivery....

Obstetricians are trying to follow the guidelines provided by the Royal College and are adopting a policy of CS as recommended. However, the short- and long-term maternal complications and the effects on family and society, which have huge emotional and economical implications, are ignored. The impact on women of developing countries has not been considered thoroughly and data have not been compared against developed countries. These developing nations are still struggling to provide basic antenatal care to mothers and reduce the maternal mortality rates (MMR). In 2005, the MMR in India was 450 per 100,000 in stark contrast to developed regions (9 per 100,000)….However, a significant decline in perinatal mortality has not been seen, despite the high CS rate in recent years and decrease in vaginal breech deliveries from 70.4% in 1994 to 13.1% in 2004....

[O]ffering CS to all patients does not improve the neonatal outcome significantly. This study highlights that case selection for planned vaginal deliveries is still a viable option.

Recently, it has been highlighted that CS is not always safe and is associated with severe maternal morbidity. In developing countries where anaemia is prevalent and blood and blood products are not readily available, abdominal delivery further contributes to high morbidity and mortality. There is a lack of support for the women, society and cultural values are different and health economy is of paramount importance....

For possible small improvements in perinatal outcomes, the impact and consequences of CS on future pregnancies in women who do not understand the benefits of antenatal care is more risky than vaginal breech deliveries....

Vaginal breech deliveries cannot always be avoided and will continue to occur, even in institutions with a policy of routine CS deliveries. There are situations such as precipitate delivery, home birth, fetal anomaly or fetal death and mother’s preference for vaginal birth. As a result, it is essential for clinicians to maintain the skills needed for breech deliveries. Moreover, at the hospital catering for this kind of population, several patients will continue to choose vaginal breech delivery....

CS section should be performed in selected cases after full consideration and with the involvement of the patient and their relatives and where appropriate, with a clear indication and aim of what is going to be achieved. It is ironic that where maternal morbidity and mortality is very high we are concentrating on a very small subset to reduce the perinatal morbidity and mortality. This study highlights that vaginal breech delivery remains a viable option in some patients and should be discussed with patients with a full explanation. They might choose maternal health as a priority and accept the small risk to the neonate. [Emphasis mine]

Vaginal birth is generally considered better for mothers than cesarean section, as one avoids the operative complications associated with major abdominal surgery and an increased cost of birth. In developed countries, the risk of maternal death due to cesarean delivery is 2 to 30 times higher than that observed with the vaginal births. However, in developing countries, these figures are alarming, where there are 3-6 maternal deaths for every 1000 cesarean deliveries and where every eighth in-hospital maternal death is attributed to cesarean section. Moreover, trial of scar is associated with the risk of uterine rupture (7/1000) and there is a significantly greater post-partum morbidity after repeat cesarean section than after a vaginal delivery.

In Pakistan, this issue is further complicated by the lack of adequate documentation about the indication for the previous cesarean section, the stage of labor at which it was performed, the type of uterine incision and the course of post-operative morbidity/recovery. Moreover, the patient’s desire to avoid cesarean birth due to social pressure may result in avoidance of antenatal care and hospital deliveries in subsequent pregnancies. As more and more obstetricians turn towards elective cesarean section as delivery mode of choice for breech infants, the trainee obstetricians would loose [sic] the opportunity to acquire skills for safe vaginal birth, with the resultant loss of this delivery option to be offered to the parents.

[T]he policy of wholesale Caesarean section for delivery of term breech infants as being advocated and practiced in many centers in developed countries needs re-appraisal. There is no clear benefit of abdominal delivery where strict selection criteria is employed...increased maternal morbidity attending abdominal delivery would make Caesarean delivery a less favourable option, especially in our environment where there is a great aversion to Caesarean section and where the woman cannot be guaranteed to report for monitoring in subsequent pregnancy if at all such monitoring facility is widely available.

However, the meta-analysis by Hofmeyr and Hannah (2001), which alluded to the findings of previous authors [Golfier 2001, Herbst 2001, Hannah 2000], did not assess the cost and future morbidity as a result of the caesarean section scar. This will be very relevant in our society, where grandmultiparity is common and patients may be having their 6th or 7th caesarean section….

Although it may be difficult to elucidate clearly the reasons for these changes, there is no doubt about the fact that the preferred route of delivery of a singleton breech at term is by elective caesarean section in the developed world. Perhaps we need to consider whether it is necessary to follow management trends elsewhere in the world without taking cognisance of the culture of the society in which we practice…. [Emphasis mine]

Our community, being a developing one, still prides itself on the size of the family and, as such, it seems logical to try to allow vaginal delivery in breeches with the safety of the mother and baby still the priority. With a sizable proportion of childbearing women in our society being grandmultiparae, the risks of repeat caesarean section especially placenta praevia accrete increases. It was shown by Zaki et al. (1998) that the incidence of emergency hysterectomy in cases of placenta praevia accreta was 50% compared to 2% in non-accreta. It will therefore seem reasonable to attempt to reduce the trend of caesarean section for breeches in our community….

This study showed no birth trauma in 1997 while birth trauma resulting from breech delivery was highest during 2000. This may be due to the quality and experience of the registrars working in the department at the specific periods in time.

In developing world settings, and especially in rural conditions, a proper management plan before the onset of labour is often not achievable. The unpopularity of the prospect of a CS prompts women to delay admission to the labour ward until in established labour.

Increasing the number of CS should be strongly discouraged since the case fatality rate in this rural setting was found to be very high: 18/1093 women died after CS (for any indication) within 42 days after the operation (1.6%); 15 within 24 h. Haemorrhage was the major cause of death....

[The very high case fatality rate of 1.6% for CS] is a reason for great concern. We calculate that delivering 1000 babies in breech presentation by CS (excluding those whose outcome cannot be influenced by labour management) would save 137 babies, while 16 mothers would die as a result of the operation. Assuming that each woman will have two more deliveries and one third of these will be by CS, this policy would cause 656 (984 x 2/3) additional CS in the future, and 11 more maternal deaths, and this does not include the women who will die from a ruptured uterus during a subsequent pregnancy before they can have a repeat CS. Therefore, delivering all term breech presentations by CS would save 137 babies, but at least 27 women would die. In our view, this is totally unacceptable. In addition, orphaned babies also have a high risk of dying....

In this rural setting only a minority of women deliver in district hospitals. Thus, women with an easy vaginal breech delivery (at home or in a clinic) resulting in a live baby were not taken into account in this study. If all breech presentations at term were delivered by CS, then even more CS would be performed but at a lower percentage of babies would benefit.

The lack of correlation between the BrPNMR [breech-related perinatal mortality rate] and the CS rate, and the high mortality rate after CS, make a strong case against the systematic delivery of [breech presentations] by CS in this setting. Rather, attention should be given to improving the overall management of breech deliveries.

Tuesday, August 29, 2017

This gorgeous upright breech birth is worth the time to watch. The mama had originally planned a home birth, but transferred in labor to a hospital due to breech presentation. I loved watching the OB's face as she is sitting at the foot of the bed. I imagine she is thinking "Best. Day. Ever!!!" For a faster sneak preview, start the player at 6:15. You'll see the baby following all the cardinal movements of an upright breech:

Body rotates from transverse to facing straight towards the attendant ("tum to bum" as they say in the UK)

Legs go on forever, knees look turned almost inside-out, and then plop out

Chest crease or "cleavage" indicates arms will soon follow

Baby does a tummy tuck once to release its arms and once again to flex its head

This all happens so quickly that the filmmaker put the birth in slow motion.

Here is the Google Translate version of the birth, taken from the YouTube page:

Thayla was born on a rainy Sunday in May 2017. The initial plan was a home birth, but she was breech (with her butt down and her head up), so it was recommended that she be born in a hospital. The family stayed at home accompanied by midwives Paula Leal and Silvia Briani of Mamatoto team and doula Thais Olardi, until her mother, Thais, was 7 cm dilated. In this hour they went to the Hospital and Maternidade Sepaco where, after a short time, Thayla was born in a totally natural way, without any intervention, in a respectful and humanized way. In the hospital the family received the support of the obstetrician Camila Escudeiro and the neonatal pediatrician Nicole Martin.

It is with great generosity that the family opens up their intimacy and discloses the video of the birth of Thayla. Parents believe that good stories deserve to be told and that it is indeed possible for pelvic babies to be born naturally. The biggest message that Thais leaves to all mothers is: "Believe in yourself, believe in the strength and perfection of your bodies!"

Clareou Films took great pleasure in following this story and is flattered to share with you a story of faith, determination and a beautiful happy ending!

Congratulations to the dads and thank you for sharing this special moment in your life with other families! Welcome, Thayla

Saturday, August 26, 2017

This letter explains why I want vaginal breech birth to remain a viable option for all women. It was originally written to a member of the Coalition for Breech Birth Facebook group and shared with permission. (I added paragraph breaks for readability.)

~~~~~

Hi F___, I found your posts that had the hashtag "forcedcesareans." I searched it because I feel like very few people understand the pain I'm going through. I had a forced c-section because my baby was frank breech. I knew vaginal was possible, and that it happens in many European countries (hospitals too). I live in WA, and as anywhere else in the US, hospitals don't allow vaginal breech. I felt completely trapped, I wanted to run away before the scheduled surgery but I couldn't because I've been showered with scare tactics by the doctors.

The day of the surgery was a complete nightmare and I was in shock and scared the whole time. I felt like dying while the needle was entering my spine. "When you'll see your baby it won't matter", they said. And it didn't for a couple of minutes, because I was drugged and tired of fighting over what was no longer my pregnancy. But then I stopped taking opioids (I had to have an unmedicated birth... I didn't want anything like that! I wanted at least to go into labor...), the pain became less intense and anger grew inside of me.

I still feel angry and I feel like it's growing everyday. I still have flashbacks that some days are very frequent. And I feel angry and desperate and lost. They all knew. Everyone knew I absolutely did not want this. I cried at every appointment since the word "breech" was mentioned. I cried every day in between, and after, especially as the physical pain was decreasing, leaving space for more anger. I do not trust hospitals anymore. I hate my body now. I was loving it. I was loving my pregnancy until then. Now I feel like half a person. I have a baby but I didn't give birth. And no, I didn't. Every time I hear someone who's never had it done say "it's the same, a friend of mine had both vaginal and cs and she said there's no difference!" I get angry. I hate everything about it.

I don't trust hospitals anymore, at least not for birthing. When they saw I was in despair they kept repeating me next time I cod go for a VBAC. They were already planning my next pregnancy, exacerbating the feeling that what I was living wasn't my pregnancy anymore, and the next one too (the hospital being more TOLAC friendly than VBAC. What a joke.). They also made me feel inadequate because my baby was too sleepy from my opioid-tainted colostrum and she lost 11% of her birth weight, telling me I had to integrate with formula as my nipples were also sore.

I'll never forget what a horrible thing was done to me, all because of hospital policy and the lack of expertise. Because of their limits I had to be sliced open, had my baby removed from my body before labor even started, leaving me deeply traumatized, emotionally and physically broken, afraid of my own body and worried about my future pregnancy. I will have to report the surgery even if I will have to go to the dentist, reminding me every time that my bodily integrity is gone forever. All because my baby was head up.

Sorry for the long message... I just need to communicate how painful and horrible it is to prevent a woman from doing something so natural that her body needs. It messed up my psyche and I feel anguished about surgical birth unless strictly necessary. Thanks for reading... ❤️

Thursday, August 24, 2017

I discovered two maneuvers for assisting frank and footling breeches while wading through PubMed literature on breech from the 1950s. I've never heard of anything like it before. It was introduced by N.A. Tsov'ianov in the Russian medical journal Sovetskaia Meditsina in 1951 in an article titled New method of conduction of labor in breech presentation.

Tsov'ianov (also spelled Tsovyanov) apparently introduced two maneuvers. Maneuver I was for frank breech presentations; maneuver II was for footlings.

I'm having a hard time finding details about these maneuvers, since all of the articles are in Russian and the references on PubMed do not include abstracts. However, I did find this website about breech pregnancy and birth written hosted by Ternopil State Medical University in the Ukraine and written by I. Kuziv. A friend of mine living in Russia, Katerina Perkhova, sent me the illustrations.

Here is Kuziv's summary of the "Tsovyanov I" maneuver for breech breech babies:

The manual aid by Tsovyanov I in frank breech presentations.

The aim of the manual aid: to prepare the maternal ways to the delivery of the head and shoulders and to keep the normal attitude of the fetus.

In the frank breech presentation the fetus extremities are flexed at the hips and extended at the knees and thus the feet lie in close proximity to the head. The circumference of the thorax with the crossing on it arms and legs is larger than circumference of the head and the after-coming head deliveries easily.

The technique. The aid begins after the delivery of the buttocks. The obstetrician’s hands are applied over the buttocks, the thumbs placed on the fetus sacrum and other fingers on the legs. The doctor gently supports the legs to avoid its flexion. If the normal attitude of the fetus is keeping the head deliveries easy.

It appears that the attendant holds the legs against the torso, keeping the feet near the head for as long as possible.

Here is Kuziv's summary of the "Tsovyanov II" maneuver for footling breech babies.

The manual aid by Tsovyanov II in footling presentations.

The aim of the manual aid: To perform [convert?] the footling presentation to the incomplete breech and to prepare the maternal ways to the delivery of the head and shoulders.

The doctor covers the area of the vulva with the sterile napkin and puts up resistance to the delivery of the feet. The feet are flexing and the footling presentation becomes incomplete breech presentation. Than the delivery manage as in incomplete breech presentation.

I think the author means that this second technique converts a footling presentation into a presentation where one or both hips are flexed. "Preparing the maternal ways" refers to creating a large enough diameter in the fetal presenting parts for the fetal head to pass through easily.

Thoughts? Comments? Are the Tsovyanov methods still taught in Russia, the Ukraine, or other countries in that region?

Tuesday, August 08, 2017

Were you coerced, forced or pressured to have a procedure(s) during labor and birth? Such procedures may include: epidural, episiotomy, induction of labor, augmentation of contractions, IV medication or fluids, cesarean section, Pitocin, antibiotics or other medications, electronic monitoring, movement or lack of movement, or pushing position.

If so, we would be interested in learning about your experience.

We are conducting a study that examines the experiences of women who have been forced or coerced to have a procedure, including cesarean sections, during labor or birth. If you have had such an experience and are willing to share your experience, please click on the link at the bottom of this post. You will be directed to our secure and confidential survey site. The survey will include questions about you, your reproductive history and questions about the pregnancy, labor, and birth that involved a forced or coerced procedure(s). Participants will also be asked about any consequences of having the forced or coerced procedure. Completion of the survey is expected to take about 30 minutes. Participants names will not be used in any publication of results. To access the Spanish version of this survey, follow the link bellow and select the language option in the top right corner.

Saturday, July 22, 2017

We came home from France last Thursday night and left the next morning for a 9-hour drive up to my parent's cabin.

We blew one tire on the way up to our parent's cabin (turning the drive into a 12-hour trip), and another tire on the way home today. We are now experts in putting on the spare tire and hobbling to the nearest auto center.

Despite these misadventures our week in northern Wisconsin was fantastic.

Sunday, July 09, 2017

I just finished translating an excerpt from a French article that examines the interplay of medical information and patient choice in breech presentation. The authors include eloquent observations on how giving one-sided information to patients about the risks of vaginal breech birth, but not the risks of cesarean section, is "disinformation." They note that vaginal breech birth might face extinction in France, not for medical reasons, but because social pressures have heavily influenced obstetricians' fears and patients' preferences.

Excerpt from pp. 748-750 translated by Rixa Freeze, PhD, 2017. PDF version of the translation here.
Email me if you'd like to read the original article and see their illustrations.

Discussion
Studies debating the preferred mode of birth for breech presentation highlight the value of studying and learning obstetric maneuvers [6]. Medical information and patient preferences are both important criteria in influencing how women give birth to their breech babies. The type of medical information given to patients is crucial because it reflects obstetricians’ current fears. Moreover, the nature and bias of the information provided during consultations influences patients’ choices. Patients' preferences are also derived from their own knowledge, their interpretation of information provided by their provider, and the influence of their close associates and therefore of society as a whole.

We first analyzed written information that specifically mentions risks related to vaginal breech birth. Indeed, the very act of including information about a potential complication in a patient’s file shows that the provider has overtly presented and emphasized certain risks. Written information included in patients’ files indirectly represents providers’ attitudes towards vaginal breech birth and how they likely discuss it in person with their patients. If, during a medical discussion, providers emphasize certain complications, they can influence patients’ choices. Although our study does not reflect the totality of information given to patients about breech presentation, it nevertheless provides a good approximation of providers’ overall attitudes during consultations. There has been an almost constant increase in giving patients this type of information (Figure 1). In 1996, no additional specific information relating to the risks of vaginal breech birth was noted in patient files. In 2005, this information was found in almost 70% of files.

The value of this additional written information is debatable. Doctors have an ethical obligation to give their patients clear, unbiased, and honest information, and their care must be evidence-based. Thus, exclusively presenting the complications of vaginal breech birth without presenting the complications of cesarean section clearly shows how current controversies over mode of birth for breech presentation are influencing the type of information given to the patients. This one-way information is likely not fair or unbiased. This type of information is, in effect, disinformation, since patients only learn about the risks of vaginal breech birth but not about the risks of cesarean. Patients’ choices can therefore be influenced by providers who give their patients written materials to protect themselves from medico-legal risks linked to the duty of informed consent. A possible solution may lie in standardizing the information provided to the patient and in presenting the risks of both planned vaginal breech birth and cesarean in a fair and honest manner [7,8]. Creating such a document is difficult and must take into account different varieties of obstetric practice. While documents on the modalities and complications of cesarean section have been produced by obstetrical societies, there is no such document concerning breech presentation. Until the French College Gynecologists and Obstetricians (CNGOF) produces a patient information sheet, patient information is currently based solely on what each individual provider or institution provides.

The second criterion that we analyzed, maternal choice, is probably influenced by providers but also by the beliefs of the patient or those around her. The rate of maternal demand for cesarean section for a term breech presentation was less than 10% until 2000, the year the Term Breech Trial was published. Since then, planned cesarean section solely for maternal choice has steadily increased to 25% today. In contrast, demand for cesarean section upon hospital admission, in patients who had previously consented to a vaginal breech birth during a consultation, increased at a slower rate. Nevertheless, this still occurs in nearly 15% of cases. This rate is particularly alarming since a cesarean performed during labor leads to increased maternofetal morbidity compared to planned caesarean section. Thus, if we consider the total population of women admitted to hospitals with a term breech presentation, about 30% of cases end in cesarean section due to maternal choice. This figure has tripled in the space of six years.

So does the debate on breech affect medical information, or does the exposure of this debate in the media influence patient choice? It is probably a combination of these two phenomena, since comparing the curve concerning maternal choice with written information about vaginal breech birth shows similarities—in particular, a very significant increase in their respective rates beginning in the 2000s to a stagnation at the present time.

Maternal choice, which is increasing in importance, has a strong influence on the debate over mode of delivery for breech. Indeed, to maximize reduction of maternofetal risks during vaginal breech birth, providers need to adequate experience and training during residency [9]. Current maternal choices are leading to a decreased rate of vaginal breech birth. This trend also leads to a decrease in the practice and teaching of maneuvers for vaginal breech birth. If maternal choices continue to evolve over the next few years, the practice of vaginal breech birth may no longer be taught in hospitals. In the absence of a rapid change favoring vaginal breech birth, the choice of delivery route for a term breech presentation may disappear, not for medical reasons but because of a societal debate that has influenced obstetric practice.